https://doi.org/10.15218/ejnm.2020.04 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article Sexual Satisfaction among Infertile Spouses in Erbil City ABSTRACT INTRODUCTION Infertility is defined as the inability to con- ceive after one year of regular, unprotect- ed sexual intercourse. It is a common prob- lem with an estimated 10-15% prevalence rate worldwide. This common problem might have an important effect on the sex- ual lives of couples. Additionally, infertility work-up and treatment is a deeply stress- ing experience for many couples. Approxi- mately 15% of all couples experience diffi- culty to conceive after 1 year of unprotect- ed sexual intercourse (1).World Health Organization (WHO) defines sex as a bio- psychological drive that is gradually devel- oped among human children and may continue across their life cycle associated with socio-cultural and environmental fac- tors in which they born and live [2]. Sexual satisfaction is an emotional state that oc- curs with the fulfillment of individual wish- es in the area of sexual life [2]. Healthy sexual relationships lead to achievement of affinity and affection in families in addi- tion to proper satisfaction of sexual in- stincts [3]. Lack of sexual satisfaction is considered one of the most important problems, impacting an individual’s per- sonal and social lives and plays an im- portant role in one's personality develop- ment [4]. Sexual satisfaction is affected Background and objectives: Sexual satisfaction is an emotional state that occurs with the fulfillment of individual wishes in the area of sexual life. Sexual satisfaction is mainly affected by the outcomes of infertility. The study aimed to assess sexual satisfaction among infertile spouses in Erbil city and to determine associations between sexual satis- faction and their sociodemographic characteristics. Methods: A cross sectional study was conducted on 150 infertile couples visiting Materni- ty Teaching Hospital and three private infertile centers in Erbil city. Index of sexual satis- faction was used to assess sexual satisfaction. Verbal informed consent was obtained from all participants. Data was analyzed by using the frequency, percentage, Chi-square test and Fisher’s exact test from the Statistical Package for Social Sciences version 22. Results: Three hundred persons (150 infertile couples) participated in the study. Their mean age was 31.82 + 6.60 years, ranging from 17 to 49 years old. More than half of participants were less satisfied, with wives being less satisfied than their husbands. No significant association was detected between sexual satisfaction scores and level of education, occupation income and residency. Conclusion: The findings of the study indicated that more than half of participants were less satisfied, and wives were less satisfied than their husband. Infertile spouses especial- ly wives should be educated to increase their awareness regarding sexual issues. Keywords: Sexual satisfaction; Infertility; Spouses. Nergz Bayiz Abdulrehman; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. )Correspondence: nergiz.bayz89@gmail.com ) Tiran Jamil Piro; Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Iraq. 31 Erbil Journal of Nursing & Midwifery Received: 13/9/2019 Accepted: 13/11/2019 Published: 30/5/2020 mailto:nergiz.bayz89@gmail.com https://doi.org/10.15218/ejnm.2020.04 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article by different factors like job stress, couples’ struggles, education level, cultural influ- ences, and economic problems, moral, sex- ual consistency, physical and mental dis- eases [5]. Sexual dissatisfaction leads to negative mental and spiritual effects, like disappointment, depression, insecurity, unhappiness, as well as spiritual, mental and personality imbalance. These compli- cations result in diminished ability and cre- ative power, serious conflicts, as well as negative emotions as annoyance, jealousy, competition to suppress each other, lack of self-confidence and being ignored [6] The relationship between sexuality and infertili- ty is bidirectional, as the latter can be ei- ther the cause or the consequence of pos- sible sexual disturbances. It has been shown that infertility is the result of under- lying sexual disorders in only a minority of cases, while involuntary childlessness itself impairs the individual sexual functioning and the couple ’ s sexual balance [7]. Sev- eral studies have demonstrated that infer- tile couples have significantly higher rates of sexual satisfaction than fertile couple. Similarly, it has been established that those with secondary infertility have more sexual satisfaction compared with those with pri- mary infertility [8]. The study aimed to as- sess sexual satisfaction among infertile spouses in Erbil city and to determine asso- ciations between the sexual satisfaction and their selected socio demographic char- acteristics (age, gender, level of education, occupation, income, and residency) A cross-sectional study was conducted be- tween October, 8, 2018 and October, 8, 2019. A convenience sample of 150 infer- tile spouses was taken from Maternity Teaching Hospital and three private infer- tile centers in Erbil city. According to the study’s inclusion and exclusion criteria; those who were diagnosed with infertility by a gynecologist were included and infer- tile spouses with any chronic health condi- tion and psychiatric diseases were exclud- ed. Ethical approval was obtained from Ethical Committee at the College of Nurs- ing, Hawler Medical University in 26, July 2019 (number 77). Furthermore, informed oral consent was taken from the candi- date’s participation in the study, after con- firmation of confidentiality, anonymity and participants self-determination by the researcher. Formal permission was also obtained from Maternity Teaching Hospital and three private infertility centers. The Index of Sexual Satisfaction (ISS) was used to measure sexual satisfaction as a scale which was modified by the researchers. Sensitive questions had been paraphrased in order to be acceptable by the participants, and the 6 points Likert scale was made of 3 points either 0, none of the time, 1 sometimes, 2 most of the time. The total of the scores obtained from the 19 questions was calculated. The maxi- mum total score for satisfaction was 38 scores. Finally, the spouses were catego- rized into two groups, those with >29 were classified as more satisfied and those with ≤ 29 were classified as less satisfied Data was analyzed using the Statistical Package through Social Sciences (SPSS, version 22). Categorical variables were presented as proportions, and numerical variables were summarized as means and standard devia- tions. Chi-square test of association was used to compare proportions. Fisher’s exact test was used when the expected count of more than 20% of the cells of the table was less than 5. A p-value of ≤ 0.05 was considered statistically significant. Table1 shows that three hundred persons (150 infertile couples) participated in the study. Their mean age was 31.82 with a SD of 6.60 years and ages, ranging from 17-49 32 Erbil Journal of Nursing & Midwifery METHODS RESULTS https://doi.org/10.15218/ejnm.2020.04 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article the income of the majority (74%) was sufficient for daily living Figure 1 showed more than half (57%) of participants were less satisfied. The same trend existed in the wives as the majority (69.3%) were employed and 30.7% were housewives. The majority (89.7%) of the sample in urban areas. The income of the majority (74%) was sufficient for daily living Table 2 showed a significant association was de- tected within age group 39- 49 years and sexual satisfaction, with wives being less satisfied than their husbands. (P-value= 0.020 and P-value= 0.001 respectively). Non-significant associations were detected between sexual satisfaction and level of education, occupation, income and residency. years old. Table 1 also shows that the majority (47.0%) of them were between 28 -38 years old and only 14.7% were ages 39- 49 years old. The highest percentage (42.6%) of husbands graduated from institute and college, 19.3% were high school graduates, and only 2.7% of them were illiterate. Regarding the wives educa- tion most of them (48%) graduated from college and institute, and 10% were high school graduates, and only 3.3% were illit- erate. Regarding occupation, the majority (67.3%) of husbands were employed and 32.7% of them were unemployed. The same trend existed in the wives as the majority (69.3%) were employed and 30.7% were housewives. The majority (89.7%) of the sample in urban areas, and 33 Erbil Journal of Nursing & Midwifery Table 1: Basic characteristics of study sample Variables No. (%) Age (years) 17-27 115 (38.3) 28-38 141 (47) 39-49 44 (14.7) 6.60 years +SD was 31.82 +Mean age Gender Male 150 (50) Female 150 (50) Residency Rural 31 (10.3) Urban 269 (89.7) Income Sufficient for daily living 222 (74) Insufficient 40 (13.3) Exceed need 38 (12.7) Education level Husband ---------------- No. (%) Wife ---------------- No. (%) Illiterate 4 (2.7) 5 (3.3) Read and write 0 (0) 3 (92) Primary school 23 (15.3) 21 (14) Secondary school 25 (16.7) 28 (18.7) High school 29 (19.3) 15 (10) Institute and college graduate 64 (42.6) 27 (48) Post-graduate 5 (3.3) 6 (4) Total 150 (100) 150 (100) Occupation Employed 101 (67.3) 104 (69.3) Unemployed 49 (32.7) 46 (30.7) Total 150 (100) 150 (100) https://doi.org/10.15218/ejnm.2020.04 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 34 Erbil Journal of Nursing & Midwifery Figure 1: Determine the level of sexual satisfaction Table 2: Distribution of sample by feeling satisfied with each item of the index of sexual satisfaction Most of the time Sometimes None of the time Index of Sexual Satisfaction (ISS) )%( No. )%( No. )%( No. Items 76)) 228 (20.7) 62 (3.3) 10 (1) I feel that my partner enjoys our sex life 2)) 6 27)) 81 (71) 213 2) Sex is fun for my partner and m) 8)) 24 41.7)) 125 (50.3) 151 (3) Our sex life is monotonous 14)) 42 64)) 192 (22) 66 (4) When we have sex it is too rushed and hurriedly completed 32)) 96 60.7)) 182 (7.3) 22 (5) I enjoy the sex techniques that my partner likes or uses 37.7)) 113 43)) 129 (19.3) 58 (6) I feel that my partner wants too much sex from me 46.3)) 139 38.3)) 115 (15.3) 46 (7) My partner dwells on sex too much 66.3)) 199 29)) 87 (4.7) 14 (8) I try to avoid sexual contact with my partner 68.3)) 205 28.3)) 85 (3.3) 10 (9) I feel that sex is a normal function of our relationship (58) 174 36.7)) 110 (5.3) 16 (10) My partner does not want sex when I do 75.3)) 226 20.3)) 61 (4.3) 13 (11) I feel that our sex life really adds a lot to our relationship 72)) 216 25.7)) 77 (2.3) 7 (12) My partner is very sensitive to my sexual needs and desires 35.7)) 107 55)) 165 (9.3) 28 (13) I speak about sexuality with my partner 3)) 9 28.3)) 85 (68.7) 206 (14) I would live better without sexuality 59)) 177 (33.7) 101 (7.3) 22 15 I reach orgasm during sex) 2)) 6 15.6)) 47 (82.3) 247 )16) Sexuality scars me 37.3)) 112 51.3)) 154 (11.3) 34 ) feel that my sex life is boring11) 62.3)) 187 (34) 102 (3.6) 11 (18) I am satisfied with the frequency which I have sexual intercourse 62.6)) 188 34.6)) 104 (2.6) 8 (19) I am satisfied with the amount of time my partners) and I spend together immediately after intercourse https://doi.org/10.15218/ejnm.2020.04 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 35 Erbil Journal of Nursing & Midwifery Table 3: Association between Socio-demographic characteristics and sexual satisfaction levels Variables Sexual Satisfaction Scores More satisfied Less satisfied P value No. (%) No. (%) Age( years) 17-27 57 (49.6) 58 (50.4) 28-38 61 (43.3) 80 (56.7) 39-49 11 (25) 33 (75) 0.020 S Gender Male 82 (54.7) 68 (45.3) Female 47 (31.3) 103 (68.7) 0.001 VHS level of education Illiterate 3 (33.3) 6 ( 66.7) Read and write 0 0)) 3 (100) Primary school 17 (38.6) 27 61.4)) Secondary school 23 (43.4) 30 (56.6) High school 24 (54.5) 20 (45.5) Institute graduate 17 (32.1) 36 (67.9) College graduate 39 (47) 44 (53) Post graduated 6 (54.5) 5 (45.5) 0.269 NS Occupation Employed 92 (44.9) 113 55.1)) Unemployed 37 (38.9) 58 61.1)) 0.334 NS Residency Rural 14 (45.2) 17 (54.8) Urban 115 (42.8) 154 (57.2) 0.797 NS Income Sufficient for daily living 103 (46.4) 119 (53.6) Insufficient 13 32.5)) 27 67.5)) Exceed need 13 34.2)) 25 65.8)) 0.133 NS *By Fisher’s Exact Test. https://doi.org/10.15218/ejnm.2020.04 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 36 Erbil Journal of Nursing & Midwifery This study was conducted among infertile spouses in Maternity Teaching Hospital and three private infertile centers. The present study demonstrated that more than half of infertile spouses had less sexu- al satisfaction. A study conducted in Iran found that low sexual satisfaction was less common among infertile couples com- pared to fertile which was inconsistent with present study [9]. Another supported study also conducted in Iran found that in 292 couples (63.4%) of them had high sexual satisfaction, and only a few of them (0.7%) were dissatisfied which was differ- ent from our findings [10]. Regarding age, the current study results indicated that there was a significant association be- tween older ages and sexual satisfaction as, wives were less satisfied compared to their husbands. Results of the current study were in contrast to a study conduct- ed in Japan entitled sexual satisfaction of infertile couples, that they revealed sexual satisfaction of male partners was signifi- cantly lower than those of female partners between ages 30 or older [11]. Another study conducted in Iran comparison of quality of life, sexual satisfaction and mari- tal satisfaction between fertile and infer- tile couples, found that when couple's age decreases the sexual satisfaction increas- es. Conversely, when couple’s age increas- es, their sexual satisfaction decreases. Considering the fact that increase in age is followed by psychological and social changes in the individuals and the society has a negative attitude toward sexual be- haviors in higher ages, increase in age can be mentioned as one of the reasons for reduction of sexual satisfaction [10].The current study results found that no signifi- cant association was detected between sexual satisfaction and couple's education- al level. A study conducted in Nigeria on sexual dissatisfaction among female patients of reproductive age revealed that a higher educational attainment in- creases the chance that spouses can speak about their sexual problems [12]. Regarding occupation, the present study's findings indicated that no signifi- cant association was found between sex- ual satisfaction and occupation. The re- sults were consistent with a study's re- sults carried out by Khoei et al. who found no relationship between couples occupation, and sexual sat-isfaction [13]. Regarding residency, the current study showed that sexual satisfaction was not associated with place of living. The pre- sent results were supported by a study conducted in Turkey regarding sex. It was found that there was no relation- ship between place of living and sexual satisfaction [14]. Regarding family in- come, no association was found be- tween income and sexual satisfaction in this study. A study carried out by Velten and Margraf conducted in Germany about how individual, partner, and rela- tionship factors impact sexual satisfac- tion within partnerships, differed with the present study as it revealed that in- come was positively related to sexual satisfaction among spouses, and found that higher socioeconomic status is also associated with better mental and physi- cal health which are correlated with higher sexual satisfaction [15]. The findings of the study indicated that more than half of participants were less satisfied. A significant association was detected between sexual satisfaction and age group (39-49 years), and also wives were less satisfied than their hus- bands. Infertile spouses especially wives should be educated to increase their awareness regarding sexual issues. 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